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ScienceDirect Comprehensive Psychiatry 55 (2014) 475 – 482 www.elsevier.com/locate/comppsych

Anomalous self-experiences contribute independently to social dysfunction in the early phases of schizophrenia and psychotic bipolar disorder Elisabeth Haug a,⁎, Merete Øie a, b , Ole A. Andreassen c , Unni Bratlien a , Andrea Raballo d , Barnaby Nelson e , Paul Møller f , Ingrid Melle c a

Innlandet Hospital Trust, Division of Mental Health, Norway b Department of Psychology, University of Oslo, Norway c KG Jebsen Centre for Psychosis Research, Institute of Clinical Medicine, Division of Mental Health and Addiction, University of Oslo, and Oslo University Hospital, Norway d Department of Mental Health and Pathological Addiction, AUSL di Reggio Emilia, Reggio Emilia, Italy e Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne f Department of Mental Health Research and Development, Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Norway

Abstract Background: Psychotic disorders are associated with significant social dysfunction. Anomalous self-experiences (ASE) present in psychotic disorders could contribute to social dysfunction. Aim: To investigate if ASE contribute to social dysfunction in the early phases of psychotic disorders after controlling for factors related to social functioning including diagnoses. Methods: ASE were assessed by means of the EASE (Examination of Anomalous Self-Experience) in 76 patients referred to their first adequate treatment for schizophrenia or psychotic bipolar disorder. Diagnoses, symptom severity, and functioning were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Premorbid Adjustment Scale, Global Assessment of Functioning—Split Version, and Social Functioning Scale. Neurocognitive assessments included measures of psychomotor speed, working memory, executive and memory functions. Duration of untreated psychosis was also assessed. Results: High levels of ASE were significantly associated with poorer social functioning in the early phases of schizophrenia and psychotic bipolar disorder also after correcting for diagnosis. Conclusion: This study demonstrates the significance of ASE for social dysfunction in patients with psychotic disorders, and contributes to the understanding of the complexity of illness-related factors that affect social functioning. © 2014 Elsevier Inc. All rights reserved.

1. Introduction The major psychotic disorders, i.e. psychotic bipolar disorder and schizophrenia, are associated with significant social dysfunction [1–3], to the extent that social dysfunction constitutes part of the diagnostic criteria in the DSM-IV [4]. Social function is a heterogeneous concept, comprising both social roles, i.e. the part people play as members of a

⁎ Corresponding author at: Innlandet Hospital Trust, Division of Mental Health, 2840 Reinsvoll, Norway. Tel.: +47 95781487; fax: +47 62581401. E-mail address: [email protected] (E. Haug). 0010-440X/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.11.010

social group, and actual social performance. Several factors are associated with social dysfunction in people with schizophrenia, most prominently neurocognitive impairments [5] and negative symptoms [6]; but not positive symptoms to the same extent [6]. This impairment is often already present at first treatment contact in people with these disorders, and is at this point associated with childhood maladjustment and duration of untreated psychosis (DUP) [7–10]. Social dysfunction is also present among people at risk of developing psychosis and might contribute to the prediction of psychosis onset [11]. In people with bipolar disorder, social dysfunction appears to be associated with neurocognitive impairments [12–14] and also with

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persisting depressive symptoms [15]. Recent studies also show that social dysfunction is present among people with bipolar disorder even in euthymic phases of the disorder [13,14,16] and at first treatment contact [15,17]. One study found that the social dysfunction was related to the course of untreated disorder, as persons with previous untreated episodes of mania had more dysfunction at treatment onset than those experiencing their first episode [17]. Recently there has been a renewed focus on phenomenology in psychotic disorders, including studies of anomalous self-experiences (ASE; disturbance of basic self-awareness or sense of self) [18–21]. Within the frame of continental phenomenology, the notion of sense of self (or identity feeling) can be described on three hierarchical but interconnected levels: the narrative, the reflective, and the prereflective self [22]. The narrative self refers to particular explicit characteristics, like personality and the narratives of the self; whereas the reflective self is the awareness of a stable “I” over time and situations. The prereflective self is the most basic level of self-awareness, implicit, preverbal, and inseparable from subjective experience per se. This prereflective self-awareness is a necessary basis for the other two levels. ASE are subtle disturbances of the basic self, affecting the person’s deepest sense of being, the experience of him- or herself as a vital subject, naturally immersed in the world, and the sense of continuity and coherence in self-experience [22,23]. ASE include certain and subtle forms of depersonalization, anomalous experiences of cognition and stream of consciousness, self-alienation, pervasive difficulties in grasping familiar and taken-for-granted meanings, unusual bodily feelings and existential reorientation, resulting in communication and social disturbances [24]. The variants of selfdisorders should however not be considered as separate symptoms, but as overlapping aspects of a whole or gestalt. ASE are believed to underpin several conventional symptom dimensions such as positive, negative and disorganized psychotic symptoms [23] and found to be linked to depression and suicidality [25,26]. Basic self-awareness is the primary ground for the intentionality of consciousness, that is, the directedness of consciousness towards others and the world [23], and is therefore clearly related to social relatedness and functioning [27]. ASE include unusual bodily feelings, which may disrupt the more unconscious bodily resonance with other people in face-to-face interaction since mirroring and intuitive awareness are important to grasp the meanings and attitudes of another person [27]. Another aspect of ASE is disturbed “common sense”, implying that different aspects of the person’s inner world and the manifold shared everyday realities are no longer self evident [28,29]. For example, a patient said that she did not understand why people said “hello” to each other every time they met. It seems self-evident that this disruption of intuitive consensual social understanding will have a negative impact on social functioning [19,22,27]. Despite the prima facie reason to believe that ASE would influence social functioning and,

some indications of a relationship in help-seeking adolescents, we are not aware of any previous empirical study of the relationship between ASE and social dysfunction in patients with psychotic disorders. Recent studies indicate an overlap in the genetic vulnerability between schizophrenia and bipolar disorder [30]. The conventional clinical symptoms in schizophrenia and bipolar disorder are also partly overlapping [4]. Even if ASE are present to a larger extent in schizophrenia spectrum disorders [19–21], they are also modestly present in psychotic bipolar disorder [18,20]. To study if ASE independently contribute to social dysfunction in psychotic disorders we here chose to include a wider range of disorders, including both schizophrenia spectrum- and psychotic bipolar disorders. Our hypothesis was that high levels of ASE are related to poorer social functioning even after controlling for other factors known to be related to social functioning; including premorbid adjustment, duration of untreated psychosis, neurocognitive function, negative symptoms, other aspects of current symptomatology and diagnosis.

2. Materials and methods The current study is part of the Norwegian Thematically Organized Psychosis (TOP) Study and involved all psychiatric treatment facilities in two neighbouring Norwegian counties (Hedmark and Oppland, population 375,000 people). Inclusion criteria were: Age 18 to 65 years; consecutive in- or outpatients referred to their first adequate treatment for a DSM-IV diagnosis of schizophrenia spectrum psychosis (schizophrenia, schizophreniform disorder and schizoaffective disorder) (SZ) or psychotic bipolar disorder (bipolar disorder I and NOS) (BP). Receiving first adequate treatment was defined as not having previously received adequate antipsychotic medication for 12 weeks or until remission. Patients with bipolar disorder had to present psychotic symptoms, and first adequate treatment was defined as first treatment for a manic episode. Being a naturalistic study, there was some variation in treatment status (including medication). Some patients had just started treatment and some had made contact with the treatment system but not yet initiated treatment at the time of inclusion. Exclusion criteria were: head injury with neurological complications, neurological disorder and mental retardation (IQ b 70, Wechsler Abbreviated Scale of Intelligence; WASI) [31]. Patients with concurrent substance use disorders were not excluded as long as they did not meet the criteria for DSM-IV substance induced psychotic disorder. To enhance statistical power, we also included 16 patients consecutively enrolled in a closely related ongoing study of young psychosis patients born in 1985/86. They met the same inclusion and exclusion criteria except for the strict definition of first treatment, but they were all in an early phase of their treatment course, with an even shorter mean

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duration of untreated psychosis (DUP) than the strict first treatment patients. To assure valid assessment of neurocognitive test performance, all participants were required to score 15 or above on the forced recognition trial of the California Verbal Learning Test (CVLT II) (all did). The patients were also required to be stable, in the sense of not being disturbed by overt psychotic symptoms interfering with a lengthy interview or neurocognitive assessment. In that case the interview was postponed until the patients were able to participate. Fifty-six patients with SZ and twenty patients with BD completed the full protocol, including assessments of self-disorders, social functioning, and neurocognitive testing (Table 1). All patients were, as defined by the inclusion criteria, early in their treatment course, with 60 (78 %) in the very beginning of first adequate treatment. All participants provided written, informed consent. The study was approved by the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate. 2.1. Clinical assessments Diagnoses were ascertained by two experienced psychiatrists using the Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (SCID-IV) [4]. Symptom severity and function were assessed using standard psychiatric measures including the Structured Table 1 Demographic and clinical characteristics. Number of patients Schizophrenia Bipolar disorder Demographics Male gender, n (%) Age years, mean (SD) Education years, mean (SD) NART IQ, mean (SD) DUP weeks, median (range) Alcohol abuse last 6 months, frequency (%) Drug abuse last 6 months, frequency (%) PANSS, mean (SD) PANSS total PANSS positive PANSS negative PANSS general Depression CDSS, mean (SD) EASE total score (SD) Functional level, mean (SD) GAF function SFS total score IQ, mean (SD) WASI Verbal IQ WASI Performance IQ

56 20 37 (49) 25.1 (7.4) 11.4 (2.1) 104.5 (6.2) 78 (0–2040) 7 (12.5) 6 (10.7%) 70.1 (19.6) 16.9 (5.6) 16.6 (7.2) 37.3 (9.9) 8.2 (6.1) 20.2 (12.3) 38.6 (10.2) 103.6 (9.3) 93.4 (14.9) 98.1 (14.5)

NART IQ = National Adult Reading Test (premorbid IQ); DUP = duration of untreated psychosis; PANSS = Positive and Negative Syndrome Scale; CDSS = Calgary Depression Scale for Schizophrenia; EASE = Examination of Anomalous Self-Experience; GAF = Global Assessment of Functioning; SFS = Social Functioning Scale.

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Clinical Interview for the Positive and Negative Syndrome Scale (SCI-PANSS) [32]. Data on childhood adjustment were collected using the Premorbid Adjustment Scale (PAS) [33]. In this study we used the initial (i.e. childhood) sum score. Duration of untreated psychosis (DUP) was measured as time from onset of psychosis (first week with a score of four or more on one of the of the PANSS subscale items: delusions, hallucinatory behaviour, grandiosity, suspiciousness/persecution or unusual thought content). Assessment of depression was based on the Calgary Depression Scale for Schizophrenia (CDSS) [34]. Both raters completed the TOP study group’s training and reliability program with SCID training based onand supervised by the UCLA training program [35]. For DSMIV diagnostics, mean overall kappa for the standard diagnosis of training videos for the study as a whole was 0.77, and mean overall kappa for a randomly drawn subset of study patients was also 0.77 (95% CI 0.60–0.94). Intra Class Coefficients (ICC 1.1) for the other scales were: PANSS positive subscale 0.82 (95% CI 0.66–0.94), PANSS negative subscale 0.76 (95% CI 0.58–0.93), PANSS general subscale 0.73 (95% CI 0.54–0.90), and GAF-F 0.85 (95% CI 0.76–0.92). 2.2. Assessment of social functioning Social functioning was assessed with the comprehensive 79-item self-report Social Functioning Scale (SFS) [36], a scale specifically designed for schizophrenia. SFS measures different areas of social functioning, including social roles, lack of competence and social performance. It is divided into 7 subscales: (1) Withdrawal (time spent alone, initiation of conversation, social avoidance). (2) Interpersonal behavior (number of friends/having a romantic partner, quality of communication). (3) Pro-social activities (engagement in a range of common social activities, e.g. going to the cinema). (4) Recreation (engagement in a range of common hobbies, interests etc.). (5) Independence-competence (the ability to perform skills necessary for independent living, like shopping for groceries, doing laundry and taking care of personal hygiene). (6) Independence-performance (the actual performance of those same skills). (7) Employment (engagement in productive employment or a structured program of daily activity). Higher scores indicate better functioning. The subscales scores are standardized with a mean of 100 with a SD of 15, based on a sample of 334 individuals with schizophrenia. Thus, the mean SFS total score for schizophrenia is 100. The scale has been shown to be reliable, valid and sensitive in measuring social functioning in schizophrenia for both the original English and for the Norwegian version and works well also for patients with bipolar disorder [37]. The scale was administered to all participants in the same session as the neurocognitive assessment. Psychosocial functioning was in addition rated by the two assessors using the Global Assessment of Functioning Scale, Split version (GAFSymptoms and -Function) [38]. The Function part assesses the overall level of social and occupational functioning

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during a specified time period, with scores from 1 (severe malfunction) to 100 (excellent function). The Global Assessment of Functioning (GAF) [38] and the Social Functioning Scale (SFS) [36] are currently the two most commonly used scales to measure social functioning in psychosis [39]. 2.3. Assessment of self-disorders ASE were assessed according to the Examination of Anomalous Self-Experience (EASE) manual [24], comprising five domains: (1) Cognition and stream of consciousness. (2) Self-awareness and presence. (3) Bodily experiences. (4) Demarcation/transitivism. (5) Existential reorientation. This represents a wide variety of anomalous self-experiences condensed into 57 main items and scored on a 5-point Likert scale (0–4), in which 0 = absent; 1 = questionably present; 2 = definitely present, mild; 3 = definitely present, moderate; 4 = definitely present, severe. For the purpose of the analyses, the resulting scores were dichotomized into 0 (absent or questionably present) and 1 (definitely present, all severity levels). The EASE measures life-time occurrence of ASE. Each EASE interview lasted 30–90 min. EH was trained by one of the authors of the EASE (PM), and conducted all the interviews. The inter-rater reliability (IRR) for the EASE items was found to be very good [21,40,41]. 2.4. Neurocognitive assessment The neurocognitive tests in this study were selected to assess various neurocognitive domains important for prediction of social and occupational functioning in major psychotic disorders. Psychomotor speed: Digit Symbol from the Wechsler Adult Intelligence Scale III; WAIS-III [42,43]. Working memory: Letter Number Sequencing subtest from WAIS-III [42,43] Executive functions: The Colour–Word Interference subtests inhibition (3. condition) and cognitive flexibility (4. condition) (time in seconds) from the Delis–Kaplan Executive Function System (D-KEFS) [44].Verbal memory: Logical Memory Test (immediate memory) from the Wechsler Memory Scale [WMS] III [45]. Visual memory: Rey–Oesterrieth Complex Figure Test (ROCF) (delayed memory) [46]. The assessments were performed by clinical psychologists trained and supervised by an experienced neuropsychologist and researcher (MØ). All subjects were tested individually and received the tests in the same fixed order. Total time for all assessments was about 3 h, including breaks. Standard scores or T-scores (ROCF) according to norms were used for all tests. High score means better function. Premorbid IQ was assessed with a Norwegian Research version of the National Adult Reading Test (NART) [47,48] and current estimated IQ with the Wechsler Abbreviated Scale of Intelligence (WASI) [31].

2.5. Statistical analysis All analyses were performed with the statistical package SPSS, version 18.0. Mean and standard deviations are reported for continuous variables and percentages for categorical variables. Since DUP had a markedly skewed distribution (Table 1), a natural logarithm transformation of the variable was performed and used in all subsequent analyses. We first examined bivariate associations (Pearson correlations) between social functioning (SFS total score) and different variables assumed to be associated with social function. The multiple linear regression analyses were performed for 2 reasons. The first was to find a statistical model with a good prediction of SFS total, the second and most important reason was to investigate whether the association between SFS and EASE was due to confounding factors. The multiple linear regression analyses were thus performed hierarchically in several steps. First, all variables were entered that had a significant bivariate relationship to SFS and/or EASE in the present study or that demonstrated potential predictive power in previous studies, organized by domain (i.e. premorbid factors, symptoms, neurocognitive functioning). In most cases, we found multiple intercorrelations between variables within a domain and we here chose a subset of variables to represent the domain on the basis of the strength of their relationship to the dependent variable and the goodness of fit of the model. Variables that did not add to the model were taken out. The strength of prediction of an individual domain or variable was based on a judgment of changes in R2 and F. Continuous independent variables were examined for nonlinear relationships with the dependent variable. Only the final model is presented here. We also conducted the same analyses with clinician-rated function (GAF-f) instead of SFS total score as dependent variable.

3. Results Table 1 presents the sociodemographic and clinical features of the sample. There were no statistically significant differences between the diagnostic groups with respect to age, sex, years of education or premorbid IQ. In Table 2 we list patient quotes to illustrate some altered self-experiences relevant to social functioning. The mean SFS total score for the sample was 103.6 (SD 9.3), indicating substantial dysfunction. The mean EASE total score across diagnostic groups was 20.2 (SD 12.3). We also found highly significant correlations between social functioning and diagnostic group (schizophrenia vs. bipolar psychotic disorder, better social functioning in bipolar psychotic disorder) (r = .333 p = 0.003), and between ASE (EASE total score) and diagnostic group (schizophrenia vs. psychotic bipolar disorder, more ASE in schizophrenia) (r = −.709 p b .001).

E. Haug et al. / Comprehensive Psychiatry 55 (2014) 475–482 Table 2 Patient quotes. Sometimes, I do not know whether I have been with my friends at the cinema or somewhere else, or if we were just talking about it. I often experience that my facial expression is not in line with my feelings, thus other people may misunderstand me. I feel that I am not fully present in social settings. It is like seeing everything through a camera lens. When people act like me, I may get the feeling as if they are actually me, or perhaps the other way around. Sometimes my body moves without my will, and then I get a feeling as if my body does not belong to me. When other people do not notice me, I may feel that I am literally invisible, or that I do not exist. I know that you are present here and now, but if I turn around or leave this room, I cannot be sure if you still exist. I sometimes feel as if other people are actors, even my own parents. Sometimes I doubt that other people exist at all, that they may be just an illusion. During a conversation, I may get thoughts in my head that do not seem to be generated by me. These thoughts disturb the conversation because I start to wonder if this is what my friend is thinking. I have to concentrate very hard to know the exact position of my arms and legs because I have problems with my proprioceptive sense.

In bivariate analyses we found a moderate, but highly significant, negative correlation between social functioning (SFS total score) and ASE (r = −.398 p b 0.001), indicating that reduced social functioning was associated with high levels of ASE. There was a parallel linear association between social functioning and ASE in both diagnostic groups (SZ and BP) (Fig. 1). Further, there were statistically significant correlations between social functioning and psychomotor speed (r = .255, p = .026), DUP (r = −0.238 p = .038), and between social functioning and childhood adjustment (PAS childhood score) (r = −.311 p = .006) (Table 3). We also found significant correlations between social functioning and

Fig. 1. Association between social functioning and ASE.

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Table 3 Correlation between Social functioning and other patient characteristics. Social functioning Correlation coefficient (Sig, 2-tailed) PANSS PANSS pos. PANSS neg. PANSS gen. PANSS total Depression a Neurocognitive function (test name) Verbal memory (Logical Memory Test, Wechsler Memory Scale III) Visual memory (Rey–Oesterrieth Complex Figure Test) Working memory (Letter Number Span from WAIS-III) Psychomotor speed (Digit Symbol from WAIS-III) Executive functions (The Colour–Word Interference subtests from the Delis–Kaplan Executive Function System) Inhibition Cognitive flexibility Childhood adjustment LnDUP b Diagnostic group c GAF f d EASE total score

−.378⁎⁎ −.227⁎ −.469⁎⁎ −.415⁎⁎ −.536⁎⁎

(.001) (.048) (b.001) (b.001) (b.001)

.142 (.222)

.214 (.063) .131 (.260) .255⁎ (.026) .171 (.139)

.200 (.086) −.311⁎ (.006) −.238⁎ (.038) .333⁎ (.003) .509⁎⁎ (b.001) −.398⁎⁎ (b.001)

a

CDSS total score. Logarithmic transformation of DUP (Duration of Untreated Psychosis). c Schizophrenia vs. Bipolar disorder. d Global Assessment of Functioning (clinician rated). ⁎ Correlation is significant at the .05 level (2-tailed). ⁎⁎ Correlation is significant at the .001 level (2-tailed). b

PANSS positive (r = −378 p = .001), negative (r = −.227 p = .048) and general scores (r = −469 p b .001), and significant correlations between social functioning and depression (CDSS total score) (r = −.536 p b .001) (Table 3). Due to the high number of significant associations between the independent variables we did a series of initial multiple linear regression analyses to determine which (sets) of variables best represented the domains of pre-treatment characteristics (childhood adjustment), neurocognition (psychomotor speed) and current symptomatology (depression). These were combined in a final multivariate linear regression analysis, with adjustment for diagnosis at the last step. ASE, psychomotor speed and current depression maintained independent significant contributions, while childhood adjustment did not, after correcting for current levels of symptomatology (Table 4). The final model, containing the level of ASE, childhood adjustment, psychomotor speed, current depression, and diagnostic group, explained 32% of the variation in SFS total score.

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Table 4 Multiple linear regression analysis with Social functioning (SFS total score) as the dependent variable. Dependent Variable: SFS total score

Standardized Sig. B

95.0% Confidence Interval for B Lower Bound

Model 1 Childhood adjustment Model 2 Childhood adjustment Psychomotor speed a Model 3 Childhood adjustment Psychomotor speed a EASE total score Model 4 Childhood adjustment Psychomotor speed a EASE total score Depression b Model 5 Childhood adjustment Psychomotor speed a EASE total score Depression b Diagnostic group c a b c

Upper Bound

−.256

.018 −134.008

−13.192

−.227 .162

.035 −126.340 .131 −1.169

−4.584 8.873

−.161 .155 −.296

.127 −106.274 .132 −1.131 .005 −2.550

13.460 8.504 −.463

−.107 .164 −.152 −.438

.262 .079 .126 b.001

−85.151 −.454 −1.767 −6.608

23.504 8.221 .221 −2.556

−.106 .209 −.258 −.420 −.182

.262 .031 .032 b.001 .117

−84.396 .463 −2.512 −6.408 −35.289

23.279 9.483 −.118 −2.362 3.986

Digit Symbol from WAIS-III. CDSS total score. Schizophrenia vs. Bipolar disorder.

The self-rated social function (SFS) showed a strong and significant association with the clinician-rated global function (GAF-F) (r = .509, p b .001) (Table 3). GAF-F was also significantly associated with EASE total score, diagnostic group, psychomotor speed, negative symptoms, CDSS total score, childhood adjustment, DUP, working memory (Letter number sequencing subtest), and visual memory (ROCF delayed memory) (data not shown in tables).

4. Discussion Our main finding confirmed our hypothesis: high levels of ASE are significantly and independently associated with poorer social functioning in the early treated phases of schizophrenia and psychotic bipolar disorder. The differences in social dysfunction between the two diagnostic groups were to a large extent explained by their differences in ASE and not by diagnostic groups. After correcting for presence or levels of several other characteristics associated with social dysfunction, the level of ASE still made an independent significant contribution to the degree of social dysfunction. The impact of psychotic illnesses on social functioning is in many ways self evident. People struggling with such severe inner distress often have markedly reduced capacity to relate and interact with others in adequate ways. The EASE

scale, which is used in this study, principally assesses basic self-experience; only a few items explore directly and explicitly the person’s experience of other people. Our results indicate however a broad relationship between ASE and subjective (and clinician’s rated) measures of social functioning. Further, our findings suggest that ASE contribute to the inner distress and reduced capacity to relate and interact with others, in people with schizophrenia and psychotic bipolar disorder. ASE are disturbances that affect the most basic sense of presence, vitality and interpersonal connectedness. The definition of several ASE even directly reflects how overwhelmingly demanding it is to fully comprehend others in social communication, both the intuitive understanding of the other’s perspective and the more deliberate attempts to understand others [24]. Moreover, people with high levels of ASE often describe a fundamental loneliness and a feeling of alienation from others. Some may even feel as if neither they, nor other people, exist at all. Some also experience a loss of self-world boundaries that leads to profound unease and anxiety when they relate to other people. It is thus not surprising that ASE are associated with social dysfunction. This may actually represent a self-reinforcing effect: Poor social understanding leading to poor social functioning again leading to minimal or restricted social interaction which in turn will reinforce poor interpersonal/social understanding. Even though the correlational nature of the findings gives no firm conclusions about causality, some speculations might seem fair. To grasp a social situation and to understand the other and his/her perspective, we use our feeling of similarity with the other, unconscious body mirroring and resonance, common sense, and feelings of continuity and meaning [27]. Some aspects of ASE even comprise feelings of not being fully human, rather an alien or a machine. Thus, the feeling of inter-subjective similarity is disrupted. Thus, on theoretical and clinical grounds, it is more likely that ASE cause social dysfunction rather than the other way around [27]. However, as noted above, there might be self-reinforcing interactions between these phenomena. The SFS was used to measure social functioning in the present study. It measures the person’s own description of his/her social functioning, and is not a direct (objective) measure of social function. However, SFS and EASE total scores were both associated with the clinician-rated global function, GAF-F, indicating that the clinician’s observation of social function does match the person’s perceived social function, and that ASE do affect not only the person’s perceived social function, but also the observed social function. We did not measure social cognition, i.e. processing, storage and use of information about other people [49], which may contribute to the observed relationship between ASE and social dysfunction. However, as Nelson and colleagues have argued [27], disturbance of the basic self, as articulated in phenomenological literature, may be a more fundamental and primary disturbance than social cognition

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difficulties, as described in cognitive research. The relationship between these two (self-disturbance and social cognition), and indeed whether they should be seen as separate constructs or rather aspects referring to the same disturbance, should be addressed in future research. To summarise, this study demonstrates the significance of anomalous self-experience for social dysfunction in patients with major psychotic disorders, and contributes to the understanding of the complexity of illness-related factors that affect social functioning. So far, no specific therapeutic interventions are developed to address this dimension of psychopathology. However, considerable clinical therapeutic experience (in explicitly addressing ASE) indicates that it is relieving and meaningful for patients to address, verbalize and explore these experiences, to reduce distress and confusion, and sometimes even to reattribute evolving psychotic interpretations of ASE. Also, optimizing the patients' compliance might prove more efficient if clinicians take the alterations of the patients' self-experience into account. Thus, exploring these phenomena may have implications for psychotherapeutic approaches and psychoeducational interventions. Further, psychosocial rehabilitation is an indispensable part of treatment for these disorders, and the current findings indicate that assessing and considering ASE will assist clinicians in understanding patients’ difficulties with social life in general.

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